Cashing in on Check-in

As hospitals face steeper challenges in collecting fees for service, bringing the revenue cycle to the kiosk may be an answer

Bruce Hallowell

As the ranks of the uninsured continue to grow, collecting payment for service is now more of a challenge than ever. Though kiosks are in use at many hospitals for check-in and registration, smart CIOs are leveraging these terminals - along with portable devices - to improve the revenue cycle at the first point of contact and keep dollars from walking out the door.

“If kiosks are going to survive, they're going to have to be an interactive device,” says Bruce Hallowell, partner and practice director for Finance and Revenue Cycle at Falls Church, Va.-based CSC. “Every time we get an opportunity to communicate with a patient, we should take advantage of it.”

And today, that communication increasingly involves payment. Hallowell says the early use of kiosks was overrated. “A kiosk in anybody's world is nothing but a Web site,” he says. “CIOs were using kiosks to look fancy but they didn't really bring anything of value.” The value, he says, is in increasing interactivity, specifically in the area of revenue.

Brent Snyder

Brent Snyder, Esq., CIO of Adventist Health System (Winter Park, Fla.) a non-profit network of 37 hospitals in the south and southwest, agrees. He says Adventist installed Galvanon (NCR, Duluth, Ga.) kiosks in its hospitals to support the portal environment used for preregistration, viewing the patient account, scheduling, and paying bills. “It is part of the revenue cycle to push for upfront payment,” says Snyder. “We're very focused on how to leverage the kiosk in that process, and that is our goal.”

But that goal has challenges, namely to automate validation from the time the patient authenticates at the kiosk, then to verify what co-pays or deductibles are required by the insurance company, and finally, to have that information displayed to the patient.

Like many CIOs, Snyder had originally been using the hospital kiosks for other functions like sign-in, wayfinding and electronically capturing of admission consent forms. “We were scanning those consents into HIM. Capturing the consent electronically reduced our cost significantly.” Snyder says once the process for electronic consents at the kiosks was in place, he was able to leverage additional success with the pre-registered patients. “From the time that pre-registration occurs, we can do the insurance verification and provide that information back on the terminal,” he says. “We're finishing up a module around the payment manager that will provide more functionality.”

Part of any CIO's strategy - and in many cases the biggest challenge - is integration. At Adventist, the kiosk is linked to the hospital system's Cerner (Kansas City, Mo.) registration system and Alpharetta, Ga.-based McKesson Series patient financial system. “We were successful in getting it completed on the Series side, so interfacing there is less of a challenge,” he says. “We have rights to the code and can modify the code on the back end if we need to.”

But real-time insurance verification remains a challenge. According to Hallowell, the bigger issue is not collecting the money - it's the insurance rules. “I should not only know what the co-pay is, but also the rules I have to follow so I don't get stuck in the denial patterns,” he says. “And that's where most hospitals are dropping the ball.”

Though integrating that insurance information is difficult, Hallowell says, there are other benefits to gain from using kiosks. While the use of kiosks for collection may increasingly be a part of the customer service/hospitality role at hospitals, leaders should be careful what they wish for. Mike Sutter, director of clinical systems at the Carle Clinic (Urbana, Ill.), says human nature can have an effect on collections at a kiosk. Sutter has NCR kiosks deployed at three sites, and is using them for co-pay. Sutter expects to expand that collection functionality when his Epic (Verona, Wis.) Resolute and Prelude systems are implemented later this year.

Sutter has seen a pattern in patient use that many may not expect. “The patients that normally would have paid cash when they presented to the desk in person to check in, now check in at the kiosk and no longer go to the desk,” he says. “Though credit card collection is up, cash collections are down, so the net result is neutral.”

In addition to kiosks, tablets are another touch-screen device that patients can use independently. At Adventist, Snyder is using them as a kiosk alternative that can also take credit card swipes and can be used anywhere in the hospital. “You can push the same content to the tablet or the kiosk,” says Snyder. At Adventist, patients waiting for morning surgeries are handed tablets in the waiting room. “If there is a co-pay due, we process that, and it allows one registration clerk to handle four or five patients at a time,” he says. “We've been an early adopter as to how much we've leveraged this in our revenue cycle.”

Tablets are also in use in the emergency room at Adventist, both for registration and collection. “We have this myth about EMTALA,” says Hallowell, referring to the Emergency Medical Treatment and Active Labor Act (see sidebar on the lower half of this page). “All EMTALA says is that you have to be medically screened - and once the patient has seen a nurse, that means the medical screen is done.” He believes tablets are a good choice for emergency room collections and registration. “The truth is,” Hallowell says, “it's not an emergency 90 percent of the time. They're sitting there for hours.”

Emergency Treatment and the Law

EMTALA is the Emergency Medical Treatment and Active Labor Act, passed in 1986 by Congress as part of the Consolidated Omnibus Budget Reconciliation Act. It requires hospitals and ambulance services to provide care to anyone needing emergency healthcare treatment, regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a result of the act, patients needing emergency treatment can be discharged only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment.

In practical terms, EMTALA applies to virtually all hospitals in the United States, with the exception of the Shriners Hospitals for Children, Indian Health Service hospitals, and Veterans Affairs hospitals. EMTALA's provisions apply to all patients - not just to Medicare patients. More than half of all emergency room care in the United States now goes uncompensated and hospitals write off such care as charity or bad debt for tax purposes.

Takeaways

Kiosks are expected to become more interactive in terms of the revenue cycle.

Consent forms and way-finding are the more traditional uses of kiosks.

The emergency room is an ideal place to use kiosk or tablet technology because of the long waits.

Using tablets before a full kiosk implementation is a sound strategy.

Another use for kiosks or tablets in the ED is initial triage, something Snyder is planning. “They can, in a simple manner, identify their medical condition and make that immediately available to the triage nurse,” he says. “That's a function we have on our roadmap.”

In the end, for kiosks to continue to be relevant, says Hallowell, better functionality on the revenue side - including autocorrect for patient identity - will be key. “We all like flashy things, and the problem is people buy them but they don't fix the process,” he says. “If I was a CIO, I'd be looking at ROI and business direction to fix a problem, not bright lights.”

At Adventist, it wasn't bright lights Snyder was looking at - it was the ROI he gained using kiosks and tablets for electronic consents. As Snyder continues to roll out functionality, he says a best practice is utilizing the tablets as part of his kiosk strategy. “Tablets allow us to migrate into the additional features and determine how well they're accepted and refine workflow without having to make a larger investment in the kiosk,” he says. “Some populations may be more accepting of kiosks depending on the hospital's clientele, so I think taking it in smaller steps and gauging it has proved a prudent approach.”